Eligibility of Blind and Other Physically Handicapped Persons for Loan of Library Materials

A.The following persons are eligible for loan service:

1. Blind persons whose visual acuity, as determined by competent authority, is 20/200 or less in the better eye with correcting lenses, or whose widest diameter of visual field subtends an angular distance no greater than 20 degrees.

2. Other physically handicapped persons as follows:

(a) Persons whose visual disability, with correction and regardless of optical measurement, is certified by competent authority as preventing the reading of standard printed material.

(b) Persons certified by competent authority as unable to read or unable to use standard printed material as a result of physical limitations.

(c) Persons certified by competent authority as having a reading disability resulting from organic dysfunction and of sufficient severity to prevent their reading printed material in a normal manner.

B.In cases of blindness, visual disability, or physical limitations, “competent authority” is defined to include doctors of medicine; doctors of osteopathy; ophthalmologists; optometrists; registered nurses; therapists; professional staff of hospitals, institutions, and public or welfare agencies (e.g., social workers, case workers, counselors, rehabilitation teachers, and superintendents). In the absence of any of these, certification may be made by professional librarians or any person whose competence under specific circumstances is acceptable to the Library of Congress. Certifying authorities must not be relatives of the applicant, even if otherwise qualified. Institutional applications for nursing homes must be signed by the director of the nursing home or their designee.

C.In the case of reading disability from organic dysfunction, competent authority is defined as doctors of medicine who may consult with colleagues in associated disciplines.

D.Qualified readers must be residents of the United States, including the several states, territories, insular possessions, and the District of Columbia, or American citizens domiciled abroad.

Lending of Materials and Classes of Borrowers

A. Veterans—In the lending of books, recordings, sound reproducers, musical scores, instructional texts, and other specialized materials, preference shall be given at all times to the needs of blind and other physically handicapped persons who have been honorably discharged from the armed forces of the United States.

B.Institutions—The reading materials and sound reproducers for the use of blind and physically handicapped persons may be loaned to individuals who qualify, to institutions such as nursing homes and hospitals, and to schools for the blind or physically handicapped for the use of such persons only. The reading materials and sound reproducers may also be used in public or private schools where handicapped students are enrolled; however, the students in public or private schools must be certified as eligible on an individual basis and must be the direct and only recipient of the materials and equipment.

Application for Free Library Service--Individual

All applications for service must be submitted with an originalcertifying signaturefrom a competent authority. Applications cannot be submitted on the internet,by e-mail, or by fax.

Department of Natural and Cultural Resources, State Library of North Carolina
Library for the Blind and Physically Handicapped
1841 Capital Boulevard, Raleigh, North Carolina 27635
Toll Free: 1-888-388-2460; Local Phone: 919-733-4376 TDD: 919-733-1462
All patron records are confidential for use by library personnel only. GS 125-18, GS 125-19.

Please read and complete all parts of this form.

Name: / Last / First / Middle Initial
Address: / Street or P. O. Box
City: / State / Zip Code / Telephone / ( )
County: / Birthday: / Gender:
Email Address:
Check here if Veteran of US Armed Forces
Please give us the name, address and telephone number of a friend or relative who does
not live with you to use in case we cannot reach you directly. / Telephone: / ( )
Name:
Email Address: / Telephone: / ( )

Indicate the primary disability preventing you from reading regular printed materials. See definitions under eligibility criteria. Check only one choice.

__ / Blindness / __ / Visual Handicap / __ / Physical Handicap
__ / Reading Disability / __ / Deaf and Blind

Do you also have a hearing impairment? If yes, indicate the degree of hearing loss: (Headphones or a special amplifier may assist severely hearing impaired persons in using recorded materials. See list of attachments later in this form.)

Moderate / some difficulty hearing and understanding speech
Profound / cannot hear or understand speech

Books and Equipment

Playback equipment and special attachments are supplied to eligible persons on extended loan. If this equipment is not being used in conjunction with recorded reading material provided by the Library of Congress and its cooperating Libraries, it must be returned to this Library.

You may borrow any of the following items: (check those you wish to receive)

Books Recorded on Digital Cartridge with Digital Player
Braille Books: grade 2 Braille only
Large Print Books: / (Print will be the size of this sample: 14 point typeface.)
Music: instructional texts and scores, primarily in Braille and large type

Note: A list of magazines available in large print, cassette tape, and Braille formats is mailed to all new library users.

Special attachments for talking-book digital players: (check any you need)

Headphones Issued only in cases where loudspeakers are not permitted
Amplifier
Special booster for use by severely hearing impaired persons. Requires separate application and medical certification of significant hearing loss
Breath Switch
Used in conjunction with Remote Control Unit to turn player on or off
Remote Control Unit
Solely for readers confined to bed or those with limited use of hands. Turns player on or off from a remote location

Language Preference

Check this box if you wish to receive books in English / OR / If you wish to receive books in other languages, list the languages

Service Preference

I wish to receive ONLY books that I request. (Catalogs will be provided.)
I will accept books selected for me by the library based on my reading preferences below

Reading Preferences

Check the types of books listed below which you prefer.

I prefer: / Fiction / Non-fiction
Adventure / Disabilities / Mysteries / Science
Aging/Retirement / Family Stories / Nature / Science Fiction
Animal Stories / Fantasy / North Carolina / Sea Stories
The Arts / Folklore/Fairy Tales / Occult/Horror / Short Stories
Best Sellers / General Fiction / Plays / Sports
Biography / Health/Medicine / Poetry / Spy Stories
Black Literature / Historical Fiction / Politics/Government / Business
Technology/Computers / History-U.S. / Psychology / Travel
Classics / History-World / Religious Inspiration / War Stories
Cooking/Homemaking / Humor / Religion (scholarly) / Westerns
Current Events / Marriage/Family / Romance
Other information about your reading interests favorite authors, series, etc.)

I donotwish to receive books that contain

strong language / violence / explicit descriptions of sex

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To Be Completed by Certifying Authority

Qualifications for certifying authority given later in this application.

I certify that the applicant named is unable to read or to use standard printed material for the reason(s) indicated earlier in this form.

Please read the eligibility criteria listed later in the form before signing.
Typed or printed name of certifying authority
Original signature of certifying authority
Title and occupation
Address
City / State / Zip Code
Telephone number & Area Code / ( ) / Date

(Rev. for Internet 09/15)